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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200416
Report Date: 05/19/2021
Date Signed: 05/21/2021 03:19:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:THEL'S BOARD AND CAREFACILITY NUMBER:
198200416
ADMINISTRATOR:WILLIAMS, THELMA E.FACILITY TYPE:
740
ADDRESS:969 W. VERNON AVETELEPHONE:
(323) 231-4544
CITY:LOS ANGELESSTATE: CAZIP CODE:
90037
CAPACITY:14CENSUS: 7DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Thelma WilliamsTIME COMPLETED:
02:30 PM
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On 5/19/21, Licensing Program Analyst/ Susan Campos, was allowed entry into the facility by Administrator, Thelma Williams, and informed Ms. Williams, the purpose of the visit was to conduct an Infection Control Inspection of the facility.

LPA and Ms. Williams toured the residential home with 8 bedrooms, and 5 bathroom, and reviewed the facility mitigation plan.

No deficiencies cited.

An exit interview was conducted, and a LIC 809 was provided to Administrator Thelma Williams.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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